The government needs an evidence-based policy on blood donations
It was announced in September 2011 that the lifetime ban on men who have sex with men (MSM) donating blood in England, Scotland and Wales would be relaxed to a 12-month deferral where they would abstain from having oral or anal sex with other men, in order to give blood.
In June 2016 it was announced that Northern Ireland will lift its lifetime ban on MSM donating blood. The new policy came into effect on September 1 2016, and will bring it in line with the rest of the country.
Find out more about the review.
Prior to 2011 and since 1983, MSM have been banned from donating blood to the National Blood Service to reduce the risk of onward transmission of HIV. Read more about the background.
As evidence has moved on since 2011, the independent review body answerable to Government for the safety of blood products, the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) will be conducting another review of who is eligible to donate blood.
Terrence Higgins Trust has been invited to sit on the SaBTO working group on blood donations. We have been calling for this review to incorporate the current lifetime ban on ex-sex workers and ex-intravenous drug users. Thanks to our pressure, SaBTO has confirmed that it will be including these groups in the review. We have been working with our colleagues in SWISH (Sex Workers Into Sexual Health) to gather evidence to be considered around ex-sex workers giving blood.
Although former intravenous drug users are unable to donate blood anywhere across Europe due to the EU Blood Safety Quality Regulations 2005 [PDF], we will seek to collate evidence to take to the Council of Europe to try to get this bit of legislation changed so that it is based on evidence and not stereotypes.
The National Blood Service - Can I give blood?
Are all lesbians, men who have sex with men (MSM), bisexuals and trans (LGBT) people barred from giving blood for one year after sexual activity?
No. The deferral does not relate to someone’s sexual identity, but to their practice. If anyone, whatever they define their sexuality as, is a man who has had sex with a man (MSM) then he is asked to defer donating blood until 12 months after his last sex with another man.
This deferral is in line with other deferrals of particular populations which are, as a group, at heightened risk of acquiring a range of sexually transmitted infections (STIs).
Isn’t it discrimination to have a different rule for men who have sex with men, and heterosexuals or lesbians?
The different rule for men who have sex with men (MSM), or rather for any man who has had sex with another man in the last year, is not based on homophobia - if it was, other LGBT people would also be barred. It is based on the incontrovertible evidence that MSM in the UK are at far greater risk than any other population, per sexual encounter, of acquiring a variety of infections such as syphilis, hepatitis B and C and, most of all, HIV.
Terrence Higgins Trust would like to see the same regulations for all - but we will only get those regulations when we have managed to reduce the risks of sexually transmitted infection (STI) transmission among MSM to the same level as that faced by most heterosexuals.
A range of other deferral times exist for injecting drug users, people who have been paid for sex and for people who have had sex in some areas of the world where HIV and other blood-borne infections are more prevalent. Again, this is based on activities that may have put them at risk. However, not all these groups were included in the review and we would like to see all group deferrals examined in the same way that the 2011 review has been conducted.
The Blood Service has to look at the balance of probabilities and assess statistical risk:
- They have a quantity of blood they need to collect and seek to take that blood from people who are at the lowest possible risk of having HIV or other blood-borne infections.
- They aim to reduce the risk as far as possible for people receiving that blood based on the best evidence available to them.
- They do not claim to be able to entirely eliminate the risk of HIV infected blood entering their supplies but the exclusions they have put in place aim to significantly decrease that risk.
Since 1985, four people have been infected with HIV in the UK through blood transfusions or products despite the current precautions.
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But HIV isn’t a 'gay disease' anymore, is it?
HIV has never been a 'gay disease', anyone can contract it.
However, statistically in the UK men who have sex with men (MSM) remain at significantly more risk of contracting HIV than their heterosexual counterparts, and they are at more risk of contracting the virus today than at any time since the onset of the epidemic 30 years ago.
Certain behaviours make it more likely that someone will contract HIV in the UK, including anal and (to some extent) oral sex between men. One in seven MSM in London are now estimated to be living with HIV, as are one in 17 MSM in the UK as a whole. These figures make it statistically far more likely that sex between two men will be where one partner has HIV and the other does not, than sex between a man and a woman. Additionally, about 12 per cent of MSM who have HIV don’t yet know it, because they remain untested.
It is unhelpful to play down the devastating impact that HIV has had on gay communities in the UK and the very great and disproportionate HIV vulnerability that gay men still face. We consistently call for investment in initiatives that improve the sexual health of MSM in the UK. While HIV is not a ‘gay disease’ it is a huge issue for MSM.
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But aren’t more heterosexual people diagnosed each year with HIV in the UK than men who have sex with men (MSM)?
Public Health England statistics show that there were 6,095 new HIV diagnoses in the UK in 2015. More than 50 per cent (3,320) of these new diagnoses were among people who probably acquired HIV through sex between men. Also, just less than half of all heterosexual infections were reported as acquired outside the UK (where a likely country of infection was reported).
In contrast, 68% of MSM who were diagnosed with HIV in 2015 probably acquired HIV within the UK. This means MSM account for around two thirds of UK sexually acquired HIV infections diagnosed in one year. Although MSM are also more likely to have an HIV test, the continuing high prevalence of HIV makes MSM the group at by far the highest risk of new HIV infection in the UK today.
Although there are more heterosexual people living with HIV in the UK, the fact that the vast majority of them probably acquired HIV overseas has important implications for the way donated blood is screened for HIV.
The best available evidence currently shows that heterosexual infection is statistically more likely to have taken place outside the UK, and that the majority of these people are not recently infected and are therefore outside the 'window period'. This means that their HIV infection will be more likely to show up using the current screening methods available to the National Blood Service. People who have had sex in high prevalence countries are already deferred.
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How is it fair that a gay man with one sexual partner in the last year is deferred, while a heterosexual man can have hundreds of sexual partners and isn’t?
It’s important to look at how statistical modelling is done. A straight man with hundreds of sexual partners would be a statistical anomaly (i.e, very unusual). The projections are based on research about what happens across populations and the truth is that men who have sex with men (MSM) are far more likely to contract HIV during the course of their regular sex life than men who have sex with women.
Anomalies do exist but it is still reasonable to run statistical projections and assessments of risk based on general epidemiological data, rather than individual cases, when looking at the integrity of the blood supply. It’s these assessments that determine what questions the Blood Service asks of people seeking to make a donation.
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But aren't these statistical models based on generalisations about what men who have sex with men (MSM) actually do?
To some extent, yes, they are. However, epidemiologists and statisticians have to make some generalisations about sexual behaviour as they are unable to look at risk-taking on an individual level when assessing risk across populations.
Epidemiology relies on statistical projection to attempt to predict the course of an epidemic and this relies on theoretical principals. However, we believe that the assumptions made in the most recent review were based on the best available research into behaviour and high risk activity at the time.
It is unfortunate that generalisations have to be made and that people have to be categorised and grouped, but we accept that in this instance it is not done in a judgemental or discriminatory fashion, but is necessary in order for sensible decisions about safeguarding the blood supply to be made.
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Shouldn’t people be allowed to assess their own risk when they answer questions before giving blood?
In an ideal world they would. However, we know that many people living with HIV did not believe that they were at risk of contracting HIV prior to their diagnosis. People aren’t always good at assessing their own risk.
Around 12% of men who have sex with men (MSM) in the UK who have HIV don’t yet know they have it.
Even people in long-term relationships that they believe to be monogamous can acquire the virus if their partner is not honest with them about the sex they are having outside of that relationship. Terrence Higgins Trust sees a significant number of men who have contracted HIV in this way. It passes no judgement on these men to say that they are at higher risk of unintentionally donating blood containing HIV.
Penetrative sex is never completely risk-free and even though using a condom greatly reduces the risk of contracting HIV, accidents do happen and sometimes people remove a condom mid-act without telling their partner. Administering a questionnaire about recent sexual behaviour to every donor, as some have suggested, would not uncover these risks as the person may be completely unaware of them.
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Can’t they test the blood before passing it on?
There is no available test that completely removes the 'window period' where someone has HIV in their blood which won’t show up in tests. It is true that 'fourth generation' or RNA testing, which has been the standard test since 2007, can give a quicker result than before, but whether the window period lasts for one week or 12 weeks, it still exists and still presents a risk. However, changes in science and technology are part of what the review has taken into account.
Not all blood products can be heat-treated to kill off viruses that they may contain. It is also important to remember that blood is still pooled and one donation is usually shared among several recipients. It should also be remembered that the recipients are unlikely to know that they are at risk until after they have potentially transmitted HIV to others.
The Blood Service freely admits that no test is 100 per cent perfect and that mistakes, however rare, can be made in the laboratory. Taking blood from populations who are at a low risk of having HIV reduces the number of infected donations that could be missed by testing which is why selection takes place before donations are given. Since 2003, there have been no new HIV diagnoses resulting from UK blood donations.
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How do UK blood donation regulations compare to other countries?
Every country with a blood service operates some regulations and these should be based on evidence and the particular epidemiology and testing methods in that country. This is why policies can vary from country to country.
A 2009 European survey of 23 blood services reported that 20 countries defer men who have sex with men (MSM) permanently (or since 1977) and three countries (Latvia, Spain and Italy) reported that they have fixed period deferrals in place. In Latvia, individual assessments are used to see if a deferral is required. In Spain, a deferral of at least six months operates after a change of partner whatever the sexuality, with a permanent exclusion for individuals who have more than one sexual partner. In Italy, a deferral of four months from the risk behaviour operates for people with multiple partners or those who have changed their regular partner. Hungary and Sweden have recently joined the EU countries with 12 month deferrals.
In Australia, Argentina and Japan, a 12 month deferral operates, and in South Africa the deferral period is six months. A review in New Zealand in 2008 led to the deferral period being reduced from 10 to five years after the last relevant sexual contact. In the USA and Canada, MSM are permanently banned from donating blood.
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What happened at the 2011 review?
Terrence Higgins Trust actively supported and was directly involved in the review of blood donation regulations by SaBTO and we pledged to support the new recommendations as long as they were evidence-based. There is a clear legal requirement in UK law that the blood supply be as safe as possible. Therefore the priority of the National Blood Service must always be to prevent blood containing HIV or other blood-borne infections from being passed to patients who receive transfusions or blood products.
We have a proud history of campaigning for LGBT rights and against homophobia and will continue to do so, but we have always believed that this is primarily a public health issue, rather than a straightforward equality issue regarding homophobic discrimination.
In this review, SabBTO announced that advances in the testing and processing of blood and other progress in scientific knowledge regarding blood borne infections, as well as details from a study on what proportion of men who have sex with men (MSM) were complying with the ban, had allowed them to reassess the restrictions based on sexual behaviour.
Some 11 per cent of MSM interviewed in the research study conducted for the review had been defying the ban; however the vast majority had not been exposed to any risk of a sexually transmitted infection. Men disregarding the restrictions were shown to be broadly supportive of the 12 month deferral.
Despite significant advances in technology to protect the blood supply, which have reduced the risk of contamination to 1 per 4.3 million donations, there are still periods of time after transmission when blood borne infections cannot be detected in blood donations. These so called ‘window periods’ vary in length between individuals and according to the type of infection. Hepatitis B in particular has a long window period with 2 distinct phases where different antibody tests are required. A 12 month deferral rules out the possibility of any donations being made during such window periods.
HIV and syphilis can both be transmitted via oral sex as well as by penetrative sex and with condoms rarely used for oral sex; there is no guarantee that a high risk group donor is infection free.
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What's the background?
The emergence of blood borne infections such as HIV and Hepatitis C in the 1970s and 80s has had a profound effect on the way that blood donation and transfusion services operate around the world. In the UK, in the early 1980s, it was discovered that a number of people in the UK had developed AIDS following blood transfusions.
This problem particularly affected hemophiliacs, whose condition made them dependent on blood products. By the end of 1983, people who were thought to be most susceptible to AIDS, such as gay and bisexual men, were asked to stop donating blood . By 1985, and the discovery that HIV was the cause of AIDS, the UK blood service began routine testing of all blood donations. All blood products were also then heat treated to destroy any possible undetected virus.
A lifetime ban on men who have sex with men (MSM) donating blood was then put into effect. Exclusions also applied to anyone who has ever been paid for sex and anyone who has ever injected drugs. In recent years there have been calls for a review of this ban as discriminatory against gay men who wished to donate blood but did not consider themselves to be at risk of HIV. Demands for a change to the ban have argued that it is an equality issue.
The National Blood Service has always responded that it is a safety issue first and that the exclusion is about specific higher risk sexual behaviour (such as oral or anal sex between men) rather than sexuality. They have argued that there is no exclusion of gay men who have never had sex with a man, or of women who have sex with women.
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